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The provider of this service has requested a review of one or more of the ratings.

Reports


Inspection carried out on 20 Feb 2018 to 22 Mar 2018

During a routine inspection

We saw improvement from the last inspection in 2015.

We rated effective, caring, responsive and well led as good, with safe being rated as requires improvement.

Inspection carried out on 02 – 05 June 2015

During a routine inspection

We undertook this inspection 02 to 05 June 2015. It was an announced comprehensive inspection. This trust had been inspected in the first wave of the comprehensive programme November 2013.

Our rationale for undertaking this inspection was to rate the trust because the initial inspections did not receive a rating due to being in the early wave one pilot programme. In addition to this the trust had taken over some services from the dissolved Mid Staffordshire NHS Trust, which included Cannock Chase Hospital.

The trust had previously stated its intention to become a Foundation trust, but had had to postpone the application a number of times; allowing them to address current matters such as the integration of new services appropriately.

We recognise that we saw this hospital, and the trust is a state of change. Integrating services between New Cross Hospital and Cannock Chase Hospital. We also noted some significant building work on the hospital site, including a new Urgent and Emergency Care unit.

We inspected all core services on the New Cross site; this included Urgent and Emergency Care; Medical Care, Surgical Care, Critical care, Maternity Services, Children’s Services, End of Life care, Outpatients and Diagnostic Imaging.

Overall we rated the New Cross Hospital as Requires Improvement.

We rated Urgent and Emergency Care and Surgical Services as Good, we rates all other services are Requires Improvement.

We rated the hospital as Good for Effective, caring and Responsive; we rated the hospital as Requires Improvement for Safe and well Led.

Our key findings were as follows:

  • Good services were provided by Urgent and Emergency Care. Safe systems were in place and the hospital was responding to the increase in demand by expanding the unit. In the interim; processes and procedures were effective.
  • Good Services were provided by Surgical Services; care was delivered within national guidance and the trust was largely meeting the 18 week referral to treatment target.
  • We saw good compliance with hand hygiene and with the trusts ‘bare below the elbows’ policy. We saw staff in outpatients remind visitors to use hand gel. On the occasions we saw non-compliance, we raised this with the clinical manager and it was immediately dealt with.
  • We saw largely good and compassionate care within the hospital. Staff were focused on patient care.
  • We did see a number of examples in medical care services that did not demonstrate the high standards of patient care set in other parts of the trust. These isolated examples demonstrated poor patient care.

  • We saw nurse staffing levels sufficient for the needs of the service including Urgent and Emergency Care and Critical Care and Children’s Care and Outpatients. However in Medical Care we saw staffing a challenge to meet the requirements of each shift. Staffing in Surgical Care was on the trusts risk register, although we saw the trust had taken action to recruit more staff.
  • There were mainly sufficient medical staff to care for patients. Children’s services and radiology had vacancies and the trust were aware of these.
  • We saw sufficient equipment across the trust to meet the needs of patients, although in medical care services there was a concern about sufficient monitoring equipment.
  • We saw that the trust was meeting cancer access targets and the 18 week referral to treatment times in outpatients and in many of its surgical specialities.

We saw several areas of outstanding practice including:

  • The hospitals SimWard was being utilised to support staff competencies. Staff told us they were in the process of expanding the service externally to provide education and learning to other authorities.
  • Doctors, nurses and therapists were provided with a stamp by the trust with their name and personal identification number. This enabled other staff to easily track who had completed the patient record when required.

  • In surgical services, we saw that the trust recently instituted “In Charge” initiative was welcomed by patients and relatives. This was a badge worn by the person responsible for that shift on the ward.
  • There were arrangements in place with Age Concern that certain patients funded by the local CCG could be called upon to transport suitable patients. There was a checklist in place for the driver who would ensure that the patient had all the necessary comforts in the home for example, food and a suitably heated home. The Age Concern drivers would stay with the patient in their home to ensure they are safe to be on their own.

  • The “panel meeting” concept where senior trust staff provided high challenge and high support to wards managers after investigation of incidents. This meeting enabled staff to take the learnings from such events on board and ensure systems were put in pace to prevent reoccurrence.
  • We saw that the mortuary staff were very passionate about delivering a high standard of care after death.

However, there were also areas of poor practice where the trust needs to make improvements.

Action the hospital MUST take to improve

Medicine

  • The trust must improve the attitude and approach of some of its staff to patients in their care.
  • The trust must improve the level of detail in patient care records, reflecting individual preferences.
  • The trust must review the amount of monitoring and supporting equipment on its wards.

Surgery

  • The trust must make sure that the recruitment of additional staff that was being undertaken to resolve the transportation of blood is completed in a timely manner.

Critical Care

  • The trust must ensure that regular checks are recorded regarding the cleaning of equipment.
  • The trust must ensure that locally owned risks are identified and recorded on the risk register and have appropriate actions to mitigate them, with timely reviews and updates.
  • The trust must ensure the medicine room is locked to reduce the risk of unauthorised people accessing medicines.
  • The trust must ensure that intravenous medicines are stored correctly to reduce the risk of the administration of incorrect medicines.
  • The trust must ensure that the microbiologist input is recorded within the patient records to support their care and welfare.

End of Life Care

  • Controlled medication must be labelled, prescribed to a patient and packaging must not be tampered with.

OPD and Diagnostics

  • The trust must ensure that when controlled drugs are removed from the medicines cupboard in radiology, this is clearly documented at the time of administration.
  • The trust must insure that governance systems improve so that safety issues and shortfalls in risk assessments and protocols are highlighted and addressed.
  • The trust must insure that there is clear ownership of responsibilities to ensure the radiology departments is working within best practice professional guidelines and IR(ME)R regulations

Action the hospital SHOULD take to improve

Emergency Services

  • The trust should improve staff understanding of the dementia care pathway for patients in the ED
  • Medicine fridge temperature records in the ED should be recorded daily to ensure medicines were stored safely.
  • Evidence of resuscitation status should be included in patient’s records.
  • ED staff take up of mandatory training should be improved.
  • The trust should be clear about the use of the paediatric facilities in the ED
  • The trust should improve public information about making a complaint in the ED

Medicine

  • The trust should improve the attitude and approach of some of its staff to patients in their care.
  • The trust should improve the level of detail in patient care records, reflecting individual preferences.
  • The trust should review the amount of monitoring and supporting equipment on its wards.
  • The trust should review arrangements for transferring patients to Cannock Chase Hospital late at night.

Surgery

  • The trust should make sure that all staff is up to date with the requirements of the Mental Capacity Act and Deprivation of Liberty safeguards so that patients are not put at unnecessary risk of staff not acting legally in their best interests.
  • The trust should make sure that there are process in place to ensure formal “sign in” takes place in the anaesthetic room.
  • The trust should make sure that a number of required policies and procedures identified from the national emergency laparotomy audit 2014 are put in place.
  • The trust should make sure that patients with bowel cancer can access appropriate clinical nurse specialist.
  • The trust should ensure there are resting seats available for vulnerable patients to avoid them to walk long intervals without resting.

Critical Care

  • The trust should ensure there are procedures in place to record the checking of the resuscitation trolley.
  • The trust should ensure that the trust’s vision and strategy is cascaded to all staff.
  • The trust should ensure that all policies and procedures are up to date and have been reviewed appropriately.

Maternity and Gynaecology

  • The trust should improve the quality of record keeping in maternity.
  • The trust should improve the checking of drugs and fridge temperatures where medicines are stored..
  • The trust should ensure emergency equipment is readily available to use.

End of Life Care

  • The trust might like to review staffing levels in particular on the oncology ward and surgical wards.
  • The trust should develop clear guidance for staff on repositioning spinal cord compression and spinal cancer patients.
  • Spinal cord compression and spinal cancer patients must be repositioned according to their assessment and trust policy. Staff should record incidents where appropriate.
  • The hospital might like to improve on communication with families and better recording of their discussions with staff, ensuring discharge is consistently discussed and they are kept informed of patient’s conditions.

OPD and Diagnostics

  • The trust should ensure that the renal unit complies with staffing requirements stipulated by the National Institute of Clinical Excellence.
  • The trust should ensure that staff in radiology receives feedback in relation to shared learning and changes in practice resulting from incidents.
  • The trust should ensure that call bells within radiology cubicles are fit for purpose and that there is clear signage outside x-ray rooms alerting patients not to enter and advising women to inform staff if they are pregnant.
  • The trust should ensure that the procedure to check whether women are pregnant prior to receiving radiography tests is improved
  • The trust should ensure that the nuclear medicine (imaging) service issues ‘written instructions’ to females who are breastfeeding and who have undergone a radio nuclide procedure.
  • The trust should ensure that Local Diagnostic Reference Levels are available for the CT scanners (and other diagnostic procedures) and that CT radiographers have a method (or written procedure available to them) of knowing when an overexposure would be much greater than intended and how this should be reported.
  • The trust should ensure that the clinical imaging protocols (operating procedures) are fit for purpose and that basic scan parameters are present that would allow an operator to follow and find operational information to be able to perform a scan safely and to check that recalled electronic settings within the scanning equipment is in concordance with the written protocol.
  • The trust must ensure that the radiation risk assessments are fit for purpose and have enough specific detail for the radiation work undertaken in each area.
  • The trust must ensure that there are Local Rules or systems of work available for mobile radiography units as required by the Ionising Radiation Regulations 1999.
  • The trust should ensure that paediatric reports within radiography are produced promptly.
  • The trust should ensure that appointment letters and patient information leaflets are available in languages other than English.
  • The trust should ensure that there is a method of monitoring whether patients have been present in outpatients or radiology for long periods to ensure they have adequate food and drink.
  • The trust should ensure that patient feedback is received and acted upon in radiology to improve service provision.
  • The trust should ensure that radioactive medicinal products and waste are securely stored and accounted for at all times.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 26-27 September 2013

During a routine inspection

The Royal Wolverhampton NHS Trust is an acute services provider with three main sites and a total of 800 beds, including 27 intensive care beds. The trust has one main acute hospital site: New Cross Hospital. The Phoenix Walk-in Centre and West Park Rehabilitation Hospital are the other sites. The trust is the largest teaching hospital in the Black Country, has an operating budget of £374 million, employs 6,800 staff and in 2011/12 treated more than 700,000 people.

The trust’s Board has had a number of member changes in the last 18 months, including the Chair, Chief Operating Officer and several non-executive directors. New Cross Hospital has been inspected six times since registration in April 2010. The trust was meeting CQC standards at the last inspection in January 2013.

We inspected this trust as part of our new in-depth hospital inspection programme. It is being tested at 18 NHS trusts across England, chosen to represent the variation in hospital care across England. Before the inspection, our ‘Intelligent Monitoring’ system indicated that Royal Wolverhampton was a medium risk trust.

Before visiting, we looked at a wide range of information we held about the trust and asked other organisations to share what they knew about it. We carried out an announced visit on 26 and 27 September 2013, and during that visit we held focus groups with different staff members from all areas of the hospital. We looked at the personal care or treatment records of patients, observed how staff were caring for people and talked with patients, carers, family members and staff. We reviewed information that we asked the trust to provide. We also held a public listening event where patients and members of the public shared their views and experiences of the trust.

The trust has performed well on the NHS 2012 Inpatient Survey and Inpatient Friends and Family Test, which was supported by positive feedback from patients during the inspection who felt that overall care was responsive and provided in a sensitive and dignified manner, specifically, feedback from patients in the outpatient clinics, and parents in the children’s care ward, was very positive.

Staff largely held positive views of the leadership of the trust, and felt supported in their roles with good access to training.

The trust has reported five ‘never events’ of retained swabs or similar incidents since August 2012, which is slightly higher than trusts of a similar size. The review team looked at the systems and processes in place to minimise ‘never events’ and noted evidence of good practice such as implementation of World Health Organisation checklists. It was also noted that the trust had taken steps to improve the leadership of cardiothoracic theatres and had brought them all under the same management structure.

We identified a number of areas where the trust requires improvement:

  • The hospital must take action to improve the responsiveness of care for older patients. We were concerned that older people’s care, surgical and dementia wards were not sufficiently staffed, particularly at night, where there was one registered nurse for every 10 patients. We felt this was impacting the safety and effectiveness of care. The trust must also ensure its dementia care bundle is implemented consistently on every ward.
  • The hospital currently has a shortage of midwives due to staff maternity leave and sickness absence. This issue has been included on the trust’s risk register and actions have been taken to improve, such as establishing a pool of maternity staff to fill gaps on rotas. Further work is needed to improve staffing levels in the maternity ward, as it is impacting on the responsiveness and effectiveness of staff.
  • There were a number of instances across the hospital where processes and systems had not been properly followed. These included infection and hygiene controls, responding to patient alarms, and following guidelines for treatment of patients with dementia.
  • During our inspection we saw examples where systems and processes intended to help people at the end of their life were not fully implemented – particularly relating to documenting decisions made about whether to resuscitate a patient.

Inspection carried out on 24 January 2013

During a routine inspection

During this inspection we observed how surgical staff completed the World Health Organisation Surgical Safety Checklist (WHO checklist) in three theatres. The WHO checklist was implemented by the World Health Organisation to improve the safety of surgery. We found that the trust had made improvements in this area since our last inspection in July 2012.

We also visited four wards and the Endoscopy Suite and spoke with patients and visitors. We found that patients were generally happy with their care and that it met their needs. One person we spoke with told us, "They do their best, really." We asked another person if there was anything they were not happy with and they told us, "Not off the top of my head." Some of the patients were not able to give us their views directly either because of their dementia or because they were too poorly. For this reason we spent time on all the wards we visited observing people’s interactions with staff. We did this for 20 people and found that staff gave them care and support that met their needs.

We found that that pressure relieving equipment was available, maintained appropriately and that staff had been trained in its use.

We found that the trust had effective measures in place to protect people from the risk of infection.

We saw that staff were supported to be trained to an appropriate standard and we looked at records which showed that the trust was regularly monitoring the quality of its service.

Inspection carried out on 25 July 2012

During an inspection in response to concerns

This inspection was carried out because there had been a number of never events at this hospital trust since May 2011. Never events are serious, largely preventable, patient safety incidents that should not occur if the available preventative measures have been implemented. A number of these related to events in theatres which is where we focused our inspection visit.

The inspection took place on 25 July 2012 and was unannounced. We were accompanied by a professional clinical advisor from the Care Quality Commission to carry out this inspection. Our visit consisted of speaking with staff, looking at policies and procedures, records and observing theatre practice. During this inspection we visited all main theatre areas, and other non-theatre areas where surgical procedures took place.

We spoke with staff who covered a range of different roles within theatres. This included medical and nursing staff who had specific responsibilities in ensuring that any surgery was completed safely. We also met with the medical director, a clinical director, a divisional medical director and the chief nurse as part of this inspection.

We did not speak with many people during this inspection because we were reviewing practice in the operating theatres. We observed staff treating people with dignity and respect. We also saw that people were put at ease and staff were observed to be kind and caring, offering reassurance at all times.

We found improvements were needed in how the trust was monitoring surgical practice in theatres. The completion of surgical safety checks has been accepted in the NHS as good practice in support of the prevention of avoidable errors and omissions in surgical care. We observed procedures where the required safety checks were fully completed by theatre staff as a team. In other procedures, some important checks were either missed or not completed with the full involvement of all members of the theatre team.

Inspection carried out on 21 March and 18 September 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 25 January 2012

During an inspection to make sure that the improvements required had been made

We undertook this review to check whether improvements had been made following our earlier inspections in March and May 2011. Whilst at the hospital, we visited two wards (D20 and D8) and the patient information centre.

Overall patients told us that they were receiving the care they needed. We were told that staff were kind, pleasant and caring. We sat on the wards and observed some of the practice. We saw that staff were busy but the atmosphere on both wards was relaxed with staff working efficiently to meet the different needs of people who had been admitted. We saw staff communicate with patients and their relatives in a sensitive way. One patient said “All are very polite and always explain what they are going to do”. When asked if anything could be improved the patient replied, “can't think of anything - all is fine - I am very satisfied with the care I am getting”.

We saw and heard about the systems in place to make sure that people were getting appropriate support with eating and drinking. We observed mealtimes on both wards which were protected which meant that patients had time to eat their meals without being interrupted. Patients told us that the food was good quality and there was always plenty of choice. We saw patients were assisted to eat and drink and that referrals were made when assessments identified a need for more specialised input.

Patients and relatives told us that they had been involved in planning their discharge home. We heard examples from both wards about the new 'e discharge' forms which gave more information to the doctor or district nurse on discharge. We were told that information supplied to nursing homes who provide a step down facility was variable and "dependent on who completed the forms". Staff told us that when referrals were made, these tend to happen quickly. One patient told us how they had been referred to a specialist whilst in hospital and had already been seen.

The trust had systems in place to assure themselves of quality. Since our March 2011 review the trust has conducted thorough and extensive investigations into five mortality outliers. An outlier is generated from routine patient data and is generally a measure that lies outside an expected range of performance. We analysed this information with other data we had. These investigations found no evidence of poor care and no avoidable deaths, but identified a small proportion of cases where there were process or system errors. Examples of good practice were also identified. Similarly we knew that any actions and learning triggered by serious incidents or complaints were monitored and reported on regularly.

There continue to be changes in how complaints were being managed. We spoke with a random sample of people who had made a complaint recently. Whilst not everyone was satisfied with the handling of their complaint, they had been satisfied with the outcome and actions taken by the trust to learn from the incidents.

Inspection carried out on 31 March 2011

During an inspection in response to concerns

Most people we spoke with told us they were satisfied with the care, support and treatment they had received on the wards we visited as part of this review and during a visit to the trust on 23 March 2011. Comments from people using the service included, “I think I have received excellent care on this ward. The staff are very polite, courteous, and respectful” and “Brilliant, nothing is too much trouble”. People also described less positive experiences in other parts of the hospital, which suggests care and support may vary between wards.

People told us of their experiences when they transferred between wards and departments and gave us varying views of whether they thought enough staff were around to meet their needs and those of other people. We found that most people were not aware of the process or where to get information about raising complaints, but said they would speak with staff if they had any concerns.

Inspection carried out on 23 March 2011

During a themed inspection looking at Dignity and Nutrition

People told us they have been pleased with the care and support they have had on the wards we looked at as part of this review. People said they felt they had a say in their treatment and what happened to them while they were in hospital. People told us their privacy and dignity is respected and their independence promoted and that staff help them if they are less able to do some things.

One person commented that they “couldn’t wish for better care”, another person described staff as “golden” but described them as being “rushed off their feet”.

Most people gave positive feedback about the quality, range and availability of food. They told us that staff had asked them what they like to eat and whether they need support with eating and drinking. One person said, “staff asked me about options and asked about allergies and they check I’ve had enough to eat” another described how staff check on them regularly and encourage them to eat and drink, however they told us they had been unable to eat their main meal commenting that they, “couldn’t eat fish, couldn’t swallow it, it was hard”.